Sadness
Grief
Dysthymic
Cyclothymic
MDD
Bipolar
14 million Americans have major affective disorder. incidence in younger women & older men.
Self-Esteem Worthlessness Concentration Symptoms never disappear for more than 2 mos @ a time Incidence to develop MDD 15 % commit suicide
2 years in a row
Hypersomnia & daytime drowsiness Appetite for carbs & sugars = wt. gain
Therapy:
Timed exposure to special light (4-6H/d) Synchronizes circadian rhythms Melatonin production = Euthymia (normal mood & usual behaviors)
Genetic Transmission via different genes (# 6 or # 11) Risk of incidence 25% 1st degree relative Hereditability 50 % Bipolar Disorder
75% identical twins
MDD Etiology
Biochemical Deficiency of neurotransmitters ACh NE, 5-HT, DA & GABA Cortisol RT response to CRF Psychosocial Anger turned inward Unresolved trauma or early life loss. Learned Helplessness = Powerless Ego Early stress contributes to self-defeating pattern Glass is empty View in a negative manner
Clinical Symptoms
Suicidal Ideation
Negative thoughts of self-hate & hostility Recurrent thoughts of death Social & personal resources Verbalize desire to die Patient getting better = Risk Lethality = Describe specific plan & access!
Need immediate intervention!
Enhance Self-Esteem
Schedule regular meeting times = Pt importance Redirect to focus on present problems Identify (+) attributes & achievements Have pt make an antidepressant kit Social interaction via group activities Assign responsibilities
Arrange chairs in dayroom for meetings
Ripping paper, throwing nerf ball, yelling Physical exercise walking releases tension
Expressing emotions via
Medications
TriCyclic Antidepressants TCAs
Formerly 1st choice Delayed onset of action 2-3 weeks
Optimal response in 1 month
Need adequate dose & duration 4-9 months Blocks reuptake of NE, 5-HT & DA Receptor sensitivity NE, 5-HT & DA available @ receptor site mood appetite activity & regular sleep patterns
TCA Medications
Amitriptyline (Elavil) Desipramine (Norpramin) Imipramine (Tofranil) Amoxapine (Asendin) Doxepin (Sinequan) Nortriptyline (Pamelor)
TCA Side Effects Dose related = dose = SE Start low & go slow Potentially lethal if 3x Max therapeutic dose
Not responsive to dialysis = fatal!
TCA Contraindications Cardiac HX (MI) Hepatic or Renal insufficiency Closed <) glaucoma
Seizures
Cardiovascular
Orthostatic BP HR Arrhythmias Prolonged QRS QT
Gastrointestinal
Heartburn
Paralytic Ileus
Cardiac Meds
BP may or
Antacids
Inhibit TCA absorption
Antipsychotics
Potentiate anticholinergic effects, EPS, sedation & seizures
Fluxoxetine(Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Clinical Signs:
Mental status
Restlessness Temp Diaphoresis Diarrhea HR Chills
Confusion
Agitation RR Ataxia
Hypomania
Myoclonus BP
Abdominal cramps
Nausea
Bupropion (Wellbutrin)
Selective DA & NE reuptake inhibitor (No affect on 5-HT) SE: Seizures Weight Nicotine craving
Atypical Antidepressants
Sexuality
SE: * BP
HR
N&V
SE: ** Sedation
Weight
Sedation
BP @ doses
Last choice due to fatal SE & drug interactions Irreversibly Inhibits monoamine oxidase (MAO)
MAO deactivates NE, DA & 5-HT & tyramine inactive products
NE
DA tyramine = BP
Anticholinergic CNS
MAOIs SE
Cardiac
GU
Hypertensive Crisis
MAOIs SE
Explosive HA (Occipital Frontal) BP (Sudden Elevation = CVA) HR , Palpitations = Chest Pain Temp, Diaphoresis, Dilated pupils = Photophobia
Thorazine 100mg IM ( Blocks NE & DA) Procardia 10 mg PO/IV ( Vasodilator) BP Regitine IV (Vasodilator) BP
SE
Transient confusion Short term memory loss
ECT
Out Pt. Procedure
Complete PE & HX
Contraindications:
Brain tumor, ICP, CVA, BP
Informed consent & NPO 6-8 hours Assess mood & thought process Remove prosthesis & void a ECT Current (70-125 volt) applied to frontal lobe
ECT Medications
Glycopyrrolate (Robinul) 0.2-0.4 mg IM 30 mins a secretions & blocks vagal reflex HR remains WNL Methohexital (Brevital) 1.5 mg/kg IV Anesthetic = RR BP & CO Succinylcholine CL (Anectine) 0.75 mg/kg IV Muscle relaxant & prevents generalized Gran mal seizure Apnea & Respiratory depression
Bipolar Disorder
Mood extremes, 1 or more manic episodes Sudden onset early 20s
Bipolar Disorder
Manic Episode
Self Esteem = Grandiosity Pressured speech & Intrusive Euphoria Aggressive, Sarcastic & Manipulative Flight of ideas & Distractible Dress Bizarrely & Makeup Psychomotor agitation = Work production Sleep only 1-2 hours/day Nutritional Status RT Dont eat or drink Pleasure seeking activities = Sexuality
Nursing Interventions
Safety
Environmental stimuli Protect from harm to self or others Consistent limit setting
Channel Energy
Redirect activities to work off energy
Na or overdose of Li
Lithium Toxicity
Diuretics = Na & Li renal clearance Renal functioning 3 Ds (Diarrhea, Diaphoresis & Dehydration)
Fluid & Electrolyte loss
Therapy
Rapid Assessments VS & LOC Hold all Li doses Hydration (5-6 L/d) NS to promote excretion Diuresis & Hemodialysis
Anticonvulsants
Used for mood stabilizing effects For Pts who failed to respond to LI Or Li contraindicated (Pregnancy, Renal, Cardiac) Divalproex (Depakote) Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Oxcarbazepine (Trileptal)
Topiramate (Topamax)
Suicide
30,000 year 2nd cause of death 15-34 age 5-6% occur in inpatient psych unit 10-20 unsuccessful attempts q suicide Risk factors
Mood Disorders Hopelessness Schizophrenia Command Hallucinations Substance Abuse Resources ($, social) Anxiety Insomnia European American > 65 years Mondays in the Spring Prior suicide attempts
Suicide
80% of attempts Pts give clues! Behavioral
Verbal cues- The pain will be over soon Obtaining a gun # 1 method. Hoarding pills & getting multiple refills Give away prized personal belongings Suicidal gestures: Non-lethal self injury acts
Affective
Ambivalence (between life & death) Loss of emotional attachments Desolation Guilt Shame Sudden Happiness or relief
Cognitive
Suicide
Poor problem solvers Fantasy Reunion Wish = meeting dead relatives Command Hallucinations Suicidal Ideation = Thought: How to method
Nursing Interventions
Take all gestures seriously! Assess suicidal intent Stay c Pt and maintain safety Establish a No harm contract
Suicide Interventions
Focus discussion on events & activities Encourage participation & attendance Interaction with # of people
Behaviors
Tears Overwhelming feelings of loss Social withdrawal Concentration Dizziness HA Anorexia/ GI symptoms Anger Anxiety Guilt Lethargy Feel Drained
Grief
Unresolved Grief
Prolonged grief Loss of self esteem Unable to resume usual routine/ADLs Psychotic symptoms Reclusiveness Psychosomatic Disorders Asthma IBD RA Acting out behavior = Hostility
Therapy
RN must 1st accept own mortality Encourage expressions of feelings Identify the degree of loss Listening = single most important communication skill! Maintain dignity & incorporate cultural/spiritual beliefs Facilitate life review & saying good by Accept loss emotionally & intellectually Realistically remember (+) & (-) aspects